Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Tuesday, March 25, 2008

Spendtacular Surgery

In order to remove an otherwise inoperable tumor, surgeons have extirpated more or less a woman's entire intestinal tract, taken away the tumor, and re-installed her guts. The operation took fifteen hours, at least two anesthesiologists, and who knows (because the article doesn't say) how many surgeons and nurses and aides. The extraordinary effort was required because of the location of the cancer, at the backside of the abdominal cavity, enwrapping itself amongst the blood supply to those gut organs. High fives all around.

It's not that it's not amazing. It's a salad of surgical steps steeped in transplantation techniques, and a melange of magic, making mayhem manageable. Had I done it, I'm sure I'd have found it exciting and dramatic, and I'd no doubt be impressed as hell with myself. TV cameras, interviews. I might even have convinced myself it was worth it; it's obvious the patient thinks so, and I don't mean to diminish that. She looks like a very nice person. (In the print version, there are pictures.)

Even forgetting for a moment that when a cancer insinuates itself into blood vessels it is almost certainly incurable (because in doing so it invades into the bloodstream and spreads elsewhere), I don't think it's unreasonable to be skeptical. Because it seems a good example of the dilemma of health care costs driving us into medical bankruptcy. In asking whether it's appropriate to do such a thing, am I out of bounds? Considering it -- given the finitude of resources -- a waste of money, am I heartless? Were I the patient, would I think differently? (Well, I think I can answer that last one in the negative: I happen to recoil [admitting the chips are not yet down] at the idea of that many people and that much money being devoted to the personal old fuck that is me, and I tell myself I'd not allow it.)

I guess it's a matter of the particular versus the abstract. The woman is a person whom many people no doubt know and love. Were she my friend or relative, were I looking her in the eye, I'd likely feel differently, and so might you. But as a matter of policy I find it troubling; or at least a good subject for discussion. I remember being outraged at Ronald Reagan (one of a bazillion times) when, shortly after demanding reduced federal funding for health care, he got all misty over a girl who'd just had (or maybe was asking for) a liver transplant (I think it was) and chipped in a few bucks for her fund. But it's how we think. Or don't think, depending on how you look at it. If we tear up in wonderment when we read such a story, then we must also be willing to pay: well up; pony up. But if we think it's an imbalance in equity, then we must also be willing to say so when it's grandma.

In my area there's an increasing crisis in hospital bed availability, and it extends to adjoining counties. Projections suggest impending shortages of surgeons nationwide. Medicare will go bust on its current trajectory. Looking at this spectacular (as in "spectacle") operation seems a good way to frame the debate: should it have been done? Should there be parameters: age, odds of cure, projected costs? Number of people required, or time taken up in an operating room? Are insurers obliged to cover such things? Is Medicare? If not, are we okay with "heroic" (I have a problem with that term, too) care being given only to those that can afford it?

I have opinions, but not answers. Answers can only come from confronting such questions straight up, in Congress and in the voting booth. Cost, benefit, society. Taxes, deficits. Priorities. In these times, of all times, it feels like the clock is ticking. Meanwhile, I wish the lady well.

30 comments:

I know what you mean. I find myself worrying about these things on a smaller scale all the time in my own practice. I mean, I have seen a caring couple agonize over whether or not to send their pet to surgery for a bleeding liver mass. Sure, it could be a hemangioma or other benign bleeding mass, and sure, it's possible we could fix it. But it's not a certainty. What *is* a certainty is that their bill is going to be at least $1500 and probably more - and when the wife cries because she wants to save her dog but the kids all need new shoes, that's when I step in and say euthanasia is a kindness, not a cruelty, and that I believe in taking care of the whole family, and not putting one member above all, as long as we do not allow anyone to suffer needlessly. Just because maybe we can do something in veterinary medicine does not mean we will. At the same time, I get annoyed with people who say "what? $200 to work-up and regulate my newly diabetic cat? I can get a new cat for $20 or free!" so there you go. But even in veterinary medicine there is a tendency to spend more and do more and more expensive things "because we can," and it's kind of getting out of control in my opinion.

I agree with both you and webhill. I found myself thinking the same sort of thoughts in residency when I would hear that a liver transplant patient was getting a THIRD liver after rejecting the first two. When does the next person in line get the liver (treatment)?

I was going to end my comment there but I have to add one more thing given webhill's comment.

Generality here: I've often wondered how most people feel it compassionate to end the suffering of their family pet yet insist that every needle stick, procedure, line, CPR etc is necessary for a 'loved one' with a known terminal illness.

I had this exact thought when pouring blood products into a "well ventilated" patient who had progressed into DIC resulting in using up nearly the entire hospital supply on one GSW patient. It was taking two ICU nurses to hook up the IVs and inflate the pressure bags and the blood was still spilling out of the patient faster than we could replace it.

There has to be a stop point. The brute fact is if we don't figure one out, one will be figured out for us by necessity. Our nation and most of us individually are so incredibly wealthy that we've developed a problem almost every human being who lived before 1900 would find inconceivable. We're so fat, rich, and happy we literally can't imagine the well running dry.

...but it will. And if we haven't made these decisions intelligently beforehand, they'll be made for us by the blunt force of reality itself.

Unfortunately if history is any guide, humanity is functionally incapable of making such a decision at any sufficiently complex or powerful level of organization. The communal resources of the many will continue to be profligately expended on the few until there aren't enough resources left. Apres moi, le deluge, etc, etc.

Awareness of this problem will hopefully inspire your readers to create living wills and, perhaps, so avoid the worst of the excesses.

I believe rationing care is necessary. Unless certain patients can pay, up front, for these heroic measures I don't feel they should be done. Like you said, it seems like this was done for spectacle and not much else. Far too often that's the ego talking of doctors who fail to do the best of the patient or society.

BTW: I just received your novel and have already poured through the first 5 chapters. Interesting reading I must say.

I also think we need rationing, but that it needs to be across the board. There needs to be set guidelines, and not one set of rules for rich people and another set for those less fortunate. It becomes very easy to say, "yes, we need to not provide care for those who can't pay" when you know darn well, that statement will not ever effect you or your family, medstudentgod.

I dont see rationing as a bad thing at all, if it is done in a moralistic and ethical manner. Also, there needs to be better advocates to inform people of the importance of medical directives. I think when grandma is laying in the ER, or even her own bed, many times people claim to want everything done to save her, becuase in reality, they dont know what her wishes are. They are afraid of making a mistake or of being accused of being heartless.

There are too many variables and every situation so different that no body of law would ever be able to create a blanket law governing these types of situations. It would be such a vaguely written law that it would, almost, certainly be ineffective as most laws on the books are. You can't tell a hard working, blue collar, unisured, American that he is unable to have a, potentially, life-saving operation because of his inability to pay. Even if the surgery only has a chance of extending his life for a few years, most people would want to live that extra time, as long as it wasn't an extreme quality of life depreciation.

Personally, I would much rather pass away than live an extra few years with severe quality of life depreciation. I wouldn't want to be a burden on my family.

I think the biggest problems, financially, for the medical field have potential solutions if something would be done. Malpractice suit caps, illegal immigrant health care (Bill their country of origin, then once they are better, send them back. Probably wouldn't get paid though). I think we need to lower health care costs by fixing these types of problems rather than denying health care, no matter how ridiculous.

aj: that's an excellent question, and one about which I can only conjecture from the cheap seats in the ballpark. Since it may well have been considered "experimental," the surgeons may not have been paid at all. If they were, I doubt there's any code for it, so they'd have gotten a fee that would reflect a very much lesser operation. Most hospitals charge an hourly rate for operating rooms. I suppose it varies but I'd guess it's now around 2K/hr, not including the equipment used which would be considerable. Anesthesia fees. Intensive care fees, floor care fees. There are unpredictable downstream costs: directly related to post-surgical issues and possible complications, and then, costs related to predicted (but not certain) recurrence. I'd guess the initial hospital charges, excluding professional fees, were at least $100K. But I was also thinking of resource management: the commitment of so many people and so many hours of high-demand and high-skill services such as OR, recovery room, ICU for one person with such a long-shot, as opposed to have them available to many other people with much better odds. Which is, of course, the most difficult calculation, philosophically, given the fact that money and beds are finite.

dr. sid, how do you feel about people going to foreign countries for transplants that they don't qualify for in the u.s.? if they pay for it completely themselves, is that okay? should they be entitled to transplant level follow up here?thanks for your thoughts.

anonymous: going overseas for transplant is not something I've heard much about; off the top of my head, the issues that come to mind are the ethics of "buying" organs and, by implication, facilitating the coercive selling of them. Of course that may or may not be the case every time. But given the waiting lists here, I'd guess that if one can go overseas and get an organ in less time, some shady dealings might be going on.

It's another matter entirely, that of getting care on return. Most doctors, and surgeons particularly, don't much like the idea of managing other doctors' problems; that's particularly true when someone has gone elsewhere "on the cheap" and then expects care back home. As to being "entitled" to such care: I'd say if they chose to circumvent the system, there'd be no entitlement, and it'd be their responsibility to work things out, presumably ahead of time. Just one man's opinion...

Another intriging and excellent post. In today's Chicago Tribune, there was an article about when Medicare & SS going bankrupt, with more outgo than income. (I've already tossed the paper, as I read in on the train). We (as in humans, Americans in particular) have to get over this incredibly selfish notion of saving at all costs. The Catholic church helps to perpetuate this. I especially appreciate webhill's comments. My previous dog had bladder cancer. I was provided with the option of giving her chemo. Taking the financials out of the picture, I could not put her through that, so I could selfishly have more time with her.Yes, I know, a dog is not a human. But why do we insist on utilizing "heroic" measures (a misnomer if ever there was one) to extend existence. I call it existence, but it usually isn't living. I watched my cousins do that to their father with stage 4 esophogeal cancer. The last few months of his existence were miserable. The mostly ignored medical advice, and was provided paliative care. They weren't doing it for him. They were doing it for themselves. Even before this, I've made certain that people know, that I NEVER want to be in similar circumstances.These aren't easy issues and decisions to grapple with. I don't mean to suggest otherwise. But these kinds of discussions need to be had with our loved ones while we're healthy.

What if there are enough resources / manpower / facilities etc to provide procedures for 100 people?

So the priority list is made, as determined by whatever triage criteria are set, irrespective of ability to pay, of course.

The fortunate 100 people get "saved". Person #101 is out of luck.

Now, what if person #101 saves up enough money to fund 3 additional procedures? So by allowing him to get the procedure, he and two additional patients get saved, thereby allowing three more people (counting himself)to derive benefit? Is that wrong?

I realize rarely is it that clearly defined, but it is true that those who contribute most to the workforce are the ones who are funding the original 100 procedures to begin with. Without the workforce, then nobody gets saved.

Bear in mind that the great prosperity achieved during the past 100 years was due in great part to a system where those who work hardest and contribute the most are motivated to so by the chance to derive proportional compensation and self-benefit.

IVF: unless I'm missing your point, it seems -- while true (the workforce) -- to be off point. In terms of what I was saying, it's more like this: what if there are resources for 100 operation "equivalents." Since resources are limited and finite, that makes sense. So then what if one person's operation is so extensive that it uses up, say, 10 equivalents. Then only 91 people get an operation. That is a more realistic scenario, at least in terms of the questions I think I was raising.

Dr S, your point is correct. I wasn't adequately addressing the specific situation of a mega-operation like this, but rather just the general idea of whether there should be any consideration at all of willingness/ability to pay as a criterion for triaging any form of medical rationing.

The only way to extend that example to THIS particular case is if the patient consuming the resources for this 10-unit mega-operation comes up with funding to cover the costs of 11 or 12 procedures. I know that is far-fetched, but I trust you get the point :)

My mother-in-law has a leiomyosarcoma, the same type as this woman, and hers is also in what we have been told is an inoperable spot. I love my MIL, but when it's gotten to that point, it's gotten to that point, and there is a time for putting fear aside and simply facing the fact squarely that each of us is given a life, and then it ends. The blessing of cancer is having and treasuring the time to make memories and to tell your loved ones you love them. You get a chance to say goodbye.

There are studies which demonstrate that across cultures, we exhibit higher rates of compassion and will donate at higher rates when a single person is observed to be in need. The rates of demonstrable compassion and offers of assistance go down as the population in need rises.

This seems somewhat counterintuitive, doesn't it?

But with a single person, we attach emotional identification, and with a group, that emotional attachment is diminished by its increasing abstract qualities. We still "think globally while acting locally".

If this woman's plight had been presented as representative of a group's situation and assistance with financing targeted for the group, I expect that the expressions of sympathy and affiliative/identification statements wouldn't have been as strong.

Some of our compassion is still very much rooted in the ability to self-identify. So the more "real" the person's experience is, the likelier we are to offer help and to "support the cause".

It's a major reason that community and public health initiatives are so difficult to garner enthusiastic and widespread support. Ditto preventive health initiatives. The need can only be imagined - can't see what has been prevented, and so, more difficult to perceive, to identify with,and to emotionally invest.

One related point - cases such as this one are heroic in investment and in "life saving". It's much sexier to join up and support something that "saves a life" instead of investing in a water treatment plant or in diesel exhaust emissions reductions, no?

I think these heroic measures are sometimes needed, abstractly speaking. Just to know how far we can push the medicine frontier. I am opposed however to have these kinds of surgeries to be common practice. I also somehow opposed to giving 20 plus meds for people that has metabolic syndrome/CHF/HTN, etc etc, unless they can pay fully on their own. I think the money spent on this surgery is too high, but if we think about it, spending medicare/aid money on people with metabolic syndrome/CHF/HTN/drug addicts etc, etc is also waste of money.

I agree that rationing of health care based on the financial and personnel constraints of the healthcare system as well as the patient's likelihood of survival, is needed. However, I don't believe that health practitioners should be in a position of making decisions about care based on whether we believe the patients are responsible for their illness.

Taking your example of not spending money on people with hypertension (and I hope i am not misrepresenting you here). . I think that if a treatment is deemed not financially viable to control this, then it should not be provided through government subsidy (Im assuming this is how it works in the USA).

However, I don't believe we should not be able to withold medications based on whether a patient has hypertension/atherosclerosis because they have eaten too much fried food compared to if they have familial hypercholesterolaemia.

Im trying to understand this poster who think people with high blood pressure should not be given medication calling it a waste of effort. I also want to know how I caused my HBP?

I have literally had it since I was a kid. First diagnosed when I was about 17 years old. Still in school, very active, not overweight. The only reason the doctor started checking it was because of daily nose bleeds. At age 19, many years ago, was when I first went on medication. Back then we didn't really have the good meds for it that we have today. This was back in the early 70s. I was on lasix for years. Now, I take 4 different meds daily. My mother also had HBP for as long as I can remember as did both of her parents. My grandmother and mother both were about 4ft 11in tall and weighed usually less than 100 pounds, so I dont understand this thinking that it is caused by our behavior. What behavior? What was I doing at age 17 that caused me to have horrible nose bleeds and a lifetime battle with HBP?

Why is it easier to blame patients for their illnesses than to just treat them?

It may be a stark opinion, but I do not believe the health care debate or rationing will be dealt with until politicians have absolutely no choice(IE when the Medicare trust funds go bankrupt in the next couple decades). Why solve a problem for the people who did not elect me(IE the 10-30year olds of today)? It really is no different than insurers who ignore preventative medicine savings because almost certainly the patient will be differently insured 20years later when the cost/medical loss of a myocardial infarction is incurred. Medicare was a gift to those who first received it in the late 1960s. They didn't pay a dime into it and received all the perks. When the pleurality of the voting population is over 60 and has paid into the medicare system for 40 years the story will be different. There will be an expectation of care.

My guess is in order to maintain the benefits they will "use democracy" to mandate coverage levels similar to that seen by today's Medicare. To future politicians, good luck getting elected on an issue like cutting health care spending when the AARP or equivalent runs the show. David Walker, the recently resigned Comptroller of the United States, puts it best in his bipartisan lectures. Here is a link to one: Page 10 is the most fascinating in my opinion.

http://www.gao.gov/cghome/d08524cg.pdf

In short, the underfunding of Medicare is roughly 50 Trillion dollars or $450,000 per household. At current estimates the Medicare burden is 90% of America’s total net worth. And this estimate includes a laughable 40% cut in physician reimbursement that cannot happen if the government expects doctors to keep seeing Medicare patients. The congress is currently unwilling to touch this issue and all 3 presidential candidates claim fiscal seriousness. However, Obama and Clinton's healthcare plans(if they can really be called such) expect to save $50Trillion by expanding individual coverage to the federal books. Disease management, administrative savings, and evidence based medicine may relieve some of the fiscal damage, but the resulting costs on my generation(I'm a 23 year old medical student)are not acceptable. Universal healthcare is a laudable goal, but I require candidates to “Show me the money” before I sign off on any of it. If the candidates want to be taken seriously on matters of Federal fiscal policy 3 things matter: Medicare, Defense Spending, and EVERYTHING else. More importantly, they matter in that order.

Although my opinion means little in the current debate, if I were in a position of influence a mighty axe would be wrought into medical spending. Starting with procedures like the ones mentioned above by Dr. Schwab and the commentators. To believe the costs of the mega-procedure are not passed on to other patients is naïve. And 3 livers are you kidding? At my institution each of those transplants runs over $200k(I forget the exact number Dr. Busittil presented) a piece. $200k on one probably forgone patient may be acceptable, but X 3 it is ludicrous.

Good air in, bad air out. Is that all? Why are there 5 forms of idiopathic pulmonary fibrosis? My apologies I don't mean to whine it just seems odd that I need to learn this and we get absolutely no education on anything that is being discussed in this post. By that I mean rationing, health care financing, Medicare reimbursement etc.

AND

Thanks for the kind words and the phenomenal book. I read it when I started medical school/started reading this blog

i see my comment strikes a chord... Apperantly, we (collectively) only think certain measures is a waste of money, if we/people we know, don't have the disease. I apologize for the comment, did not mean to stir up such an emotional response.Although, it really goes to show that nobody has any place to determine/judge what is proper/not proper, heroic/not heroic.

It's a shame that the government doesn't fund medical research more liberally. I'm sure many commonplace operations that the public takes for granted today were initially considered "heroic" or cutting edge, and very costly, at the time.

About Me

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.